Tatalaksana Asma anak

Jangka Panjang

Finny Fitry Yani

Sub Bagian Respirologi
Bagian IKA RS M Djamil-FK Unand

Courtesy UKK Respirologi Anak IDAI 2015

 Definition of asthma
Reversible respiratory tract obstruction
spontaneously or after treatment

1950-es
Is There A Cure For Asthma?

Asthma cannot be cured, but it can be

controlled

We should expect nothing less !
 Resume.

Bronchoconstriction

Chronic
inflammation

Remodeling
 Inflamasi pada asma
Inflamasi akut

Steroid
response

Chronic inflammation

Structural changes

Time

Barnes PJ
 Asthma
Triggers

Failed of Inhalant
house dustmite
Long-term Smoke
management Food

Acute attacks
 Asma, ada 2 aspek
Asma : penyakit saluran nafas kronik yang
dapat muncul berupa serangan akut
(two in one disease)

Chronic Asma
Asthma
Acute Asthma
Kunjungan 2

n Tentukan Klasikasi Derajat Penyakit

Asma

n Jika dalam keadaan serangan : tentukan

derajat serangan asma
 Goals of asthma management
The long-term goals of asthma management:
1. Symptom control
to achieve good control of symptoms and
maintain
normal activity levels

2. Risk reduction
to minimize future risk of exacerbations, xed
airow limitation and medication side-eects

GINA 2015
 Symptom - attack: a continuum
attack
attack
symptom
symptom

MPI
Asthma
MPI:
minimal
Asthma a ttack i s a r apid progressive
persistent worsening episode of symptoms
inammation (cough, dyspnea, wheezing,
chest tightness or combination)
inammation PNAA 2004
 Asthma symptoms features

n Periodicity (recurrent)
n Variability (nocturnal, worsen at night)
n Reversibility (response to asthma drugs)
n History of allergy (patient &/ family)
n Trigger factors (inhalan, ingestan, others)
 Periodicity - variability: a continuum

attack

symptom

MPI
Asthma
years
MPI:
minimal
persistent
inammation

inammation
 Periodicity - variability: a continuum

attack

symptom

MPI
Asthma
08PM 08AM 24 hrs
MPI:
minimal
persistent
inammation

inammation
 Tabel 4.2. Kriteria penentuan derajat asma
New
Klasifikasi classification of asthma
kekerapan dibuat pada kunjungan-kunjungan awal dan dibuat berdasarkan
severity
anamnesis: (PNAA 2015)
Derajat asma Uraian kekerapan gejala asma
Intermiten Episode gejala asma <6x/tahun atau jarak antar gejala 6 minggu
Persisten ringan Episode gejala asma >1x/bulan, <1x/minggu
Persisten sedang Episode gejala asma >1x/minggu, namun tidak setiap hari
Persisten berat Episode gejala asma terjadi hampir tiap hari
 PNAA 2004 vs PNAA 2015
Tabel 4.3. Kesetaraan klasifikasi PNAA 2004 dengan PNAA 2015

PNAA 2004 PNAA 2015

Episodik Jarang Intermiten
Episodik Sering Persisten Ringan
Persisten Sedang
Persisten
Persisten Berat
Steps of asthma treatment

1. Avoidance of trigger(s)

2. Avoidance of trigger(s)

3. Avoidance of trigger(s)

a. Reliever
4. Drug(s)
b. Controller
 Dua pilar penganggulangan
asma jangka panjang

1. Pengendalian pencetus (triggers)

2. Pengendalian inamasi BHR
dicapai dengan menggunakan obat
 3-point asthma management

Allergen identication and avoidance

Pharmacological therapy
Education
Pemicu
 Asthma medications
reliever controller
n to relieve / reduce to control / prevent
symptoms &/ attack symptoms &/ attack
n as needed use long term use
n bronchodilators anti-inflammations
n -agonist, xanthines, inhaled steroid, ALTR
systemic steroid oral, inhalation,
n oral, inhalation,
injection
 Controller drug

attack

symptom

MPI
Asthma
MPI: Trigger Trigger
minimal light, heavy,
persistent single combination
inammation

inammation
General principles of the management
1. Establish a patient-doctor partnership
2. Provide interventions:
non pharmacological: environmental
management
pharmacological
3. Manage in a continuous cycle (control based
asthma management)
4. Provide written action plan

GINA 2015
Pa4ent doctor partnership

Friendly manner
Allow the pa7ent to express their goals, beliefs and
concerns
Empathy and reassurance
Encouragement and praise
Provide appropriate (personalized) informa7on
Feedback and review

GINA 2015, Box 3-1

 Non-pharmacological interven4ons

Avoidance of asthma triggers/allergen

Avoidance of tobacco smoke exposure
Encourage physical activity

GINA 2015, Box 3-9

Menentukan obat-obat pengobatan jangka
panjang asma anak :
Memilih obat yang akan dipakai
Memilih cara pemberian yang efektif
dan mudah dilaksanakan
Memlihi kombinasi obat dan dosis
secara berjenjang/ bertahap/ step
wise
 Stepwise management

Advise about
high Med dose High dose Med dose non-
Severe persistent STEP 5 dose ICS ICS + LABA ICS + LTRA ICS + TSR pharmacological
therapies and
strategies
Moderate Medium Low dose Low dose Low dose Treat
STEP 3 dose ICS ICS + LABA ICS + LTRA ICS + TSR
persistent modiable risk
factors &
comorbidi7es
Mild STEP 2 Low dose ICS OR LTRA
persistent Provide guided
self-
management
STEP 1 No controller educa7on
 Intermi=ent asthma (step 1)

Preferred option
as-needed inhaled short-acting beta2-agonist (SABA)

Other options
Consider adding regular low dose ICS for patients a
risk of exacerbations:
Ever intubated for asthma
History of ICU admission
With comorbidity: allergic rhinitis, GERD

GINA 2015
 Inhaled cor4costeroids in children with persistent
asthma: dose-response eects on growth.

In prepubescent school-aged children with mild to moderate

persistent asthma:
a small but sta7s7cally signicant group dierence in growth
velocity between low doses and medium doses of ICS

favouring the use of low-dose ICS

Cochrane Database Syst Rev. 2014 Jul 17;7:CD009878

Kunjungan 3 : Tentukan Level Kontrol
asma anak (PNAA 2015)
Apa yang Dimaksud
Asma Terkontrol ?
n Gejala, termasuk gejala malam hari /(-)
n Hasil tes fungsi paru normal
n Serangan asma (-)
n Kunjungan gawat darurat (-)
n Obat pelega /(-)
n Keterbatasan dalam melakukan aktitas,
termasuk olah raga (-)
n Efek samping obat yang mengharuskan
penggantian obat (-)

TOTAL KONTROL
Asthma Severity Level vs Asthma Control
Asthma Severity Levels Asthma Control
(Intermittent, Mild Persistent, (or Current Asthma Severity)
Moderate Persistent, and
Severe Persistent)
Based on signs and Is the pa7ents current
symptoms before a severity level, regardless if
patient starts on they are on medica7ons or
controller medications not.

 The control-based
asthma management cycle
Diagnosis
Symptom control & risk factor
(including lung function)
Inhaler technique & adherenc
Patient preference
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

Asthma medications
Non-pharmacological strategie
Treat modifiable risk factors
GINA 2015, Box 3-2
 Syarat-syarat peningkatan (step up)
obat :
n Pengendalian lingkungan harus tetap baik
asmanya sudah dilakukan
n Pemberian obat sudah tepat susunannya
dan s tepat caranya
n Tindakan 1 dan 2 itu sudah dicoba selama 4
-6 minggu
n Side eect ICS tidak ada.
Maka baru ICS boleh dinaikkan
Syarat-syarat pengurangan
obat (step down) :
n Pengendalian lingkungan harus tetap baik
n Asma sudah terkendali selama 3 bulan
berturut-turut
n ICS hanya boleh diturunkan 25% setiap 3
bulannya sampai dengan dosis terkecil yang
masih dapat mengendalikan asmanya.
n Bila step down gagal perlu dicari sebab-
sebabnya dan kalau sudah dikoreksi maka ICS
dapat diturunkan bersama-sama dengan
penambahan LABA dan/atau LTRA.
 How oKen should asthma be reviewed ?

First 7me aZer controller Symptoms

started: 2 wks 1 mo Exacerbations
Then every 1-3 months Side-effects
then every 3-12 mo Patient
AZer an exacerba7on: satisfaction
within 1 week
Lung function

GINA 2015
Step up asthma treatment
Sustained step-up: for at least 2-3 months if
asthma poorly controlled
Important: rst check for common causes
(symptoms not due to asthma, incorrect
inhaler technique, poor adherence)
Short-term step-up: for 1-2 weeks, e.g. with
viral infection or allergen

GINA 2015
 Omalizumab or oral corticosteroid

2-3 months

High dose Mod dose High dose Mod dose

ICS ICS ICS + LTRA ICS + TSR
+ LABA
2-3 months

Mod dose Low dose Low dose Low dose

ICS ICS ICS + LTRA ICS + TSR
+ LABA
2-3 months

Low dose ICS OR LTRA

Stepping down asthma treatment

n When to consider stepping down ?

symptoms have been well controlled and lung

func7on stable for 3 months
No respiratory infec7on, pa7ent not travelling

GINA 2015, Box 3-7

 High dose ICS Mod dose ICS
+ LABA
> 3 months
Reduce ICS dose by 50% and continue second
controller
Moderate dose ICS Low dose ICS +
LABA
> 3 months
Reduce ICS dose by 50% Reduce ICS/LABA to once
daily
Low dose ICS Once daily ICS/LABA

> 3 months
STOP only if: no symptoms
Once daily dosing for 612 months, and
pa7ent has no risk factors
Wri=en Asthma Ac4on Plans
Developed by the health care provider for each
individual child with asthma
Key Elements:
-Daily & rescue medica7ons
-Medica7on to take with exercise
-Management of exacerba7ons
-Emergency management
Copies to be shared by clinic, family and school
When it doesnt seem right!
( inadequate response to appropriate dose of ICS )

n Poor adherence

n Poor inhaler technique

n Comorbidi7es

n Ongoing exposure to allergen

n incorrect diagnosis
PEMBERIAN OBAT INHALASI

Efek kerja cepat

Dosis rendah
Efek samping sedikit
Comparison of systemic vs inhalation
drug

Carveth, Medscape, 1999

 Cara pemberian obat hirupan

diskus
turbuhaler cyclohale
r

rotahaler MDI
OBAT SECARA INHALASI (HIRUPAN)
Choosing inhaler devices for children with asthma
Nebulizer versus holding chamber

Cochrane Database Syst Rev. 2013 Sep 13;9

Take home massages
Long-term management of asthma in children is
of importance for symptom control and reduce
future risk

Asthma medica7on should be provided by

inhala7on
Inhaled cor7costeroid is the rst choice
MDI + spacer is as eec7ve as nebulizer
Penulisan diagnosis asma anak

Kekerapan Keadaan saat ini Derajat kendali

Intermiten Tanpa gejala Tidak terkendali

Persisten ringan Gejala Terkendali sebagian
Persisten sedang Serangan ringan
Terkendali penuh dengan obat
Persisten berat Serangan sedang pengendali
Serangan berat Terkendali penuh tanpa obat
Ancaman gagal napas pengendali